A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?
Right radial pulse 4+, 80/min, palpated
Left radial pulse 1+, 80/min, palpated
Left radial pulse 4+, 80/min, palpated
Right radial pulse 2+, 80/min, palpated
The Correct Answer is A
A. Right radial pulse 4+, 80/min, palpated:
A 4+ pulse is bounding, which is consistent with the nurse’s finding. HR is documented as 80 bpm.
B. Left radial pulse 1+, 80/min, palpated:
There is no indication that the left pulse is weak or thready (which would be 1+).
C. Left radial pulse 4+, 80/min, palpated:
The left radial pulse was described as expected, not bounding.
D. Right radial pulse 2+, 80/min, palpated:
A 2+ pulse is considered normal, but the right pulse was bounding, which corresponds to a 4+ rating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Massage reddened areas during dressing changes:
Massaging reddened or compromised skin can worsen tissue damage and increase the risk of further injury.
B. Apply a heat lamp twice a day:
Heat lamps are not recommended and may dry out the wound bed or burn healing tissue.
C. Cleanse with 0.9% sodium chloride irrigation:
Normal saline is gentle and effective for cleaning granulating tissue without causing damage or cytotoxic effects.
D. Cleanse with povidone-iodine solution:
Povidone-iodine is cytotoxic and can impair wound healing, especially to new granulating tissue.
Correct Answer is C
Explanation
A. Ask the client to cough every 4 hr:
Coughing can help clear secretions, but doing so only every 4 hours is not sufficient for hypoxia. More immediate action is needed.
B. Decrease the head of the client’s bed:
Lowering the head of the bed reduces lung expansion and worsens oxygenation.
C. Encourage the client to take deep breaths:
Deep breathing improves alveolar expansion and oxygen exchange, which helps raise oxygen saturation.
D. Request a prescription for an opioid analgesic:
Opioids can depress respiratory drive, further lowering oxygen levels unless pain is clearly affecting breathing.
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